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Senior Citizen Deaths Higher than Expected from Obesity Stomach Surgery

Increasing numbers turning to Medicare-paid bariatric surgery

Oct. 19, 2005 – Senior citizens are increasingly turning to surgery of the stomach or intestines (bariatic surgery) as a way to prevent death from obesity. Three studies reported today in the Journal of the American Medical Association have found death rates higher than previously estimated, increased hospitalization rates after the surgery and a substantial increase in the number of these procedures.

Among Medicare beneficiaries, which includes most of the seniors, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.

In the United States, most adults are overweight or obese, and obesity is soon to become the leading cause of death. Bariatric surgical procedures are the only interventions that consistently help patients achieve significant and sustained weight loss and improvements in comorbid medical conditions.

As a result, there has been dramatic growth in bariatric surgery over the last decade, with interest in applying it to those at high risk based on associated medical conditions and the growing population of older, obese patients.

Balanced against these beneficial effects, however, are the risks of perioperative death and short-term adverse outcomes. These risks have been poorly defined in the community at large, with the expected rates largely derived from case series. Several high-profile reports of death after bariatric surgery have challenged these estimates and have triggered a critical reappraisal of bariatric surgical safety.

Medicare, the United States’ largest health care insurer, currently reimburses for bariatric procedures on a regional basis and is the primary payer for approximately 20% of all procedures performed in at least 1 state.

However, Medicare policy in this area is at a crossroads: there is no national coverage decision and no consensus regarding the efficacy and safety of bariatric surgery in older patients.

Following are reports on the three studies.

Risk of Death from Bariatric Surgery among Medicare Patients Higher Than Previously Estimated

Medicare patients have a substantially higher risk of early death following bariatric surgery than previously suggested, and the risk of death is higher among men, older patients, and patients of surgeons who perform lower numbers of bariatric procedures, according to a study in the October 19 issue of JAMA.

In the United States, most adults are overweight or obese, and obesity is soon to become the leading cause of death, according to background information in the article. Bariatric surgical procedures (surgery on the stomach and/or intestines designed to promote weight loss) are the only interventions that consistently help patients achieve significant and sustained weight loss and improvements with co-existing medical conditions. As a result, there has been dramatic growth in bariatric surgery over the last decade. Balanced against these beneficial effects, however, are the risks of perioperative death and short-term adverse outcomes, which have been poorly defined in the community-at-large.

David R. Flum, M.D., M.P.H., of the University of Washington, Seattle, and colleagues conducted a study to determine the risk of all-cause early postsurgical death among Medicare beneficiaries undergoing open bariatric surgery. The study examined early (30-day, 90-day, and 1-year) death figures for all U.S. fee-for-service Medicare beneficiaries who underwent bariatric procedures from 1997-2002.

A total of 16,155 patients underwent bariatric surgical procedures (average age, 48 years; 75.8 percent women, with 90.6 percent younger than 65 years). A total of 61.2 percent of cases were claims for the bariatric surgical procedure Roux-en-y gastroenterostomy (RYGB) and 19.9 percent were for RYGB with small intestine reconstruction to limit absorption. There was more than a 3-fold increase in the number of procedures performed from 1997 (n=1,464) to 2002 (n=4,814). 

The researchers found that among all patients, the rates of 30-day, 90-day, and 1-year death were 2.0 percent, 2.8 percent, and 4.6 percent, respectively. Advancing age and male sex were associated with early death after bariatric surgery, with the highest rates of early death among older men. Overall, men were more likely to die after bariatric surgery than women (3.7 percent vs. 1.5 percent, 4.8 percent vs. 2.1 percent, and 7.5 percent vs. 3.7 percent for men and women at 30 days, 90 days, and 1 year, respectively). Death rates were greater for those aged 65 years or older (n=1,517) compared with younger patients (4.8 percent vs. 1.7 percent, 6.9 percent vs. 2.3 percent, and 11.1 percent vs. 3.9 percent at 30 days, 90 days, and 1 year, respectively).

After adjustment for sex and co-existing illness index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged 75 years or older; n=136) than for those aged 65 to 74 years (n=1,381). The odds of death at 90 days were 1.6 times higher for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and co-existing illness index.

“There may be several reasons for these findings. Older patients do not tolerate surgical stress as well as younger patients and may also have less benefit after surgery than younger patients because much of the impact of obesity on organ systems, such as the heart, may have occurred by the time of the operation. It also remains to be seen if surgical weight loss in older patients decreases utilization of health care resources, improves functional status and quality of life, or extends survival as has been suggested in studies of younger patients,” the authors write.

“In conclusion, this study found that the risk of early postsurgical death among Medicare beneficiaries undergoing bariatric surgery was considerably higher than prior case series have suggested and was strongly associated with advancing age, male sex, and lower surgeon volume. Those considering the role of bariatric procedures in older patients should balance this population-level risk of adverse outcomes against the anticipated benefits of the procedure. Directing care of older patients to surgeons who perform higher volume of bariatric procedures in Medicare beneficiaries might be expected to improve outcomes in this high-risk population,” the researchers write.

Editor’s Note: This work was funded in part by grants from the National Institute of Diabetes and Digestive and Kidney Diseases.

Bariatric Surgical Procedures Increase Substantially

The number of bariatric surgical procedures performed in the U.S. from 1998 to 2003 increased considerably, according to a study in the October 19 issue of JAMA.

Morbid obesity is an increasing health problem in the United States, according to background information in the article. In 2002, 5.1 percent of U.S. adults had a body mass index (BMI) higher than 40. The prevalence of individuals with a BMI higher than 40 quadrupled from 1:200 in 1986 to 1:50 in 2000; the prevalence of individuals with a BMI higher than 50 quintupled from 1:2000 to 1:400. The increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacological interventions for morbid obesity.

Heena P. Santry, M.D., of the University of Chicago, and colleagues examined recent national population-based trends in bariatric surgical procedures, patient characteristics, and in-hospital complications to determine trends in newer techniques, in sociodemographic disparities, in co-existing illnesses, and in surgical complications due to these procedural and patient population changes.  The researchers used the Nationwide Inpatient Sample to identify U.S. bariatric surgery admissions from 1998-2002 (with preliminary data for 12 states for 2003).

The researchers found that the estimated number of bariatric surgical procedures increased from 13,365 in 1998 to 72,177 in 2002. Based on preliminary state-level data (1998-2003), the number of bariatric surgical procedures is projected to be 102,794 in 2003. Gastric bypass procedures accounted for more than 80 percent of all bariatric surgical procedures. From 1998 to 2002, there were upward trends in the proportion of females (81 percent to 84 percent), privately insured patients (75 percent to 83 percent), patients from ZIP code areas with highest annual household income (32 percent to 60 percent), and patients aged 50 to 64 years (15 percent to 24 percent). Length of stay decreased from 4.5 days in 1998 to 3.3 days in 2002. The adjusted in-hospital death rate ranged from 0.1 percent to 0.2 percent. The rates of unexpected reoperations for surgical complications ranged from 6 percent to 9 percent and pulmonary complications ranged from 4 percent to 7 percent. Rates of other in-hospital complications were low.

“If our observed rate of growth continues, there will be approximately 130,000 bariatric procedures in 2005 and as many as 218,000 in 2010. The cost to the U.S. health care system will be substantial. However, in the absence of a nonsurgical option for morbid obesity, our findings regarding in-hospital safety of bariatric surgery are promising while our findings regarding worsening sociodemographic disparities are worrisome,” the authors write.

“Disproportionate sociocultural pressures to be thin may explain the imbalance between men and women undergoing an elective procedure for weight loss. Type of insurance coverage also may play a role in socioeconomic disparities,” the researchers write. “Other sources of disparities include the possibility that cultural attitudes toward morbid obesity may differ by socioeconomic status, that primary care physicians may be less likely to refer patients of lower socioeconomic status for bariatric surgery, or that hospitals providing bariatric surgery may be less accessible to lower socioeconomic groups.”

The researchers add that public health campaigns focusing on the health dangers of obesity may help shift thinking about obesity from a cosmetic concern of women to a health concern for both sexes.

“With increased knowledge of bariatric surgery indications, risks, and benefits among health care professionals, bariatric surgery is likely to become the standard of care for morbidly obese individuals. Together, these changes should lead to more morbidly obese patients of both sexes and all socioeconomic groups seeking surgery. Although preventing obesity should remain the focus of U.S. health care, efforts must be made to ensure equal access to bariatric surgery irrespective of sex and socioeconomic status for those who are morbidly obese, have an indication for surgical intervention, and wish to undergo an elective surgical procedure to improve health, longevity, and quality of life,” the authors conclude.

Editor’s Note: Dr. Santry was supported by a fellowship from the Robert Wood Johnson Clinical Scholars Program and a pilot project grant from the National Institute on Aging to the Center on Aging at the University of Chicago, and the Dr. Paul Jordan Research Fund in Surgery at the University of Chicago.

Patients Have Increased Hospitalization Rate after Gastric Bypass Surgery

Patients who have gastric bypass surgery have double the rate of hospitalization in the year following the operation than in the year preceding surgery, according to a study in the October 19 issue of JAMA.

Bariatric surgical procedures are an increasingly common treatment for morbid obesity, according to background information in the article. More than 100,000 Roux-en-Y gastric bypasses (RYGB)—the primary bariatric procedure now done—are performed annually in the United States. A recent systematic review and meta-analysis of bariatric procedures determined that the average percentage of excess weight loss after operation was 61 percent, with rates of resolution or improvement for the following co-existing illnesses: diabetes 86 percent, hyperlipidemia 70 percent, hypertension 79 percent, and obstructive sleep apnea 84 percent.  Utilization of inpatient services after RYGB is not well understood.

David S. Zingmond, M.D., Ph.D., of the University of California, Los Angeles, and colleagues assessed the impact of RYGB on use of inpatient care by examining rates of inpatient hospitalization before and after RYGB performed in California between 1995 and 2004.

In California from 1995-2004, a total of 60,077 California residents underwent RYGB for obesity, with 11,659 in 2004.  The average age was 42.2 years, 84 percent of patients were women, and 88 percent were privately insured or self-pay. Average length of stay was 3.5 days. For patients with a year of follow-up (1995-2003), 19.3 percent were readmitted within the first year after RYGB surgery compared with 7.9 percent being admitted in the year before surgery. In a subset analysis of all patients (24,678) who underwent RYGB with complete 3-year follow-up, the average percentage of patients admitted in the year prior to RYGB was 8.4 percent. In each of the 3 years following RYGB, the rates of hospitalization remained increased, with 20.2 percent of patients readmitted in the first year after RYGB, 18.4 percent in the second year after, and 14.9 percent in the third year after. The cumulative admission rate for the 3-year period prior to RYGB was 20.2 percent compared with the cumulative 3-year admission rate after RYGB of 40.4 percent.

For persons with 3 years of follow-up, average hospital charges were $33,672 for RYGB, $4,970 for hospitalizations in the 3 years before RYGB, and $20,651 for hospitalizations in the 3 years after RYGB. In the subset of patients with full 5 years of follow-up (1995-1999), postoperative admission rates remained elevated (average 13.3 percent) in the fifth year after operation.

The most common reasons for admission prior to RYGB were obesity related problems (e.g., osteoarthritis, lower extremity cellulitis), and elective operation (e.g., hysterectomy), while the most common reasons for admission after RYGB were complications often thought to be procedure related, such as ventral hernia repair and gastric revision.

“A working hypothesis in our study was that use of health care services should likewise improve, namely that inpatient care should decrease after RYGB. However, we found significant and sustained increases in the rates of hospital admission for morbidly obese patients after RYGB. Annual rates of hospital admission after RYGB are double than prior to operation and are sustained beyond a year in this population-based study,” the authors write.

“Our findings may have implications for payers and purchasers of health care. Rather than expecting a decrease in inpatient health care utilization after RYGB, the costs associated with inpatient hospitalization may remain elevated for as many as 5 years following RYGB. Analysis of 3-year charges before and after RYGB suggest that costs of post-RYGB–related procedures and complications may be 40 percent to 60 percent of the costs of RYGB itself.”

“The potential of RYGB for yielding long-term weight reduction and alleviation of obesity-related comorbid illnesses has significantly increased the rates of RYGB over the past decade. Despite these potential benefits, the current study demonstrates that the rates of hospitalization doubles in the years after operation and that many of these admissions are directly attributable to this procedure,” the researchers conclude.

Editor’s Note: Dr. Zingmond is funded by a Mentored Clinical Scientist Award from the National Institute on Aging. Co-author Dr. McGory is funded by the Robert Wood Johnson Clinical Scholars Program at the University of California Los Angeles.

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